DWS ID NUMBER DATE QUARTER ENDED FEDERAL ID …

1 NAICS AUD CO. EMPLOYER'S quarterly CONTRIBUTION AND WAGE report . ARKANSAS DEPARTMENT OF WORKFORCE SERVICES. BOX 8007 LITTLE ROCK, ARKANSAS 72203-8007 (501) 682-3798. DWS ID NUMBER . DATE QUARTER ENDED . FEDERAL ID NUMBER . report DUE DATE. Check box and return if no wages paid c PART A. 1st mo 2nd mo 3rd mo 1. NUMBER of employees in the pay period including the 12th of: of qtr _____ of qtr _____ of qtr _____. 2. Total of all wages paid for personal services, including $ 3. Wages in excess of (see instructions).. $< 4. Out of state wages if employee(s) are paid in multiple states (see instructions).. $< 5. Taxable wages (subtract item 3 and 4 from item 2, enter results here).. $ 6. Contribution rate for this reporting _____. 7. Contribution due for this QUARTER (multiply item 5 by ).. $ 8. Amount of debit or credit from previous $ 9. Interest (accrued on all unpaid contributions at the rate of per month).. $ 10. Penalty (see instructions).. $ 11. Total amount $ 12.

2 Amount of remittance (make payable to Arkansas Department of Workforce Services).. $ CASHIER'S STAMP. DO NOT ALTER THIS FORM. Initial PART B. Enter the SSN, first name, middle initial, last name and total wages paid to each employee during the calendar QUARTER in the space provided below (continuation sheet Amt received provided). SOCIAL SECURITY NUMBER FIRST NAME, MIDDLE INITIAL & LAST NAME OF EMPLOYEE TOTAL WAGES PAID. 1) $ . 2) $ . ATTACH CHECK HERE. 3) $ . 4) $ . 5) $ . 6) $ . 7) $ . 8) $ . PAGE ONE OF _____ PAGE(S) TOTAL NO. OF EMPLOYEES TOTAL WAGES FOR THIS PAGE $ . ON THIS report _____. I HEREBY CERTIFY THIS report IS TRUE AND CORRECT AND NO PARTS OF THE CONTRIBUTION HAVE OR WILL BE BORNE BY. ANY EMPLOYEE. SIGNATURE _____TITLE _____ DATE _____ TELEPHONE _____. DWS-ARK-209B. (REV. 01-09). MAINTAIN COPY FOR YOUR RECORDS. CONTINUATION SHEET FOR FORM 209B. DWS ID NUMBER _____ QUARTER End Date _____. Employer _____. Town _____ Page _____ of _____.

3 SOCIAL SECURITY NUMBER FIRST NAME, MIDDLE INITIAL & LAST NAME OF EMPLOYEE TOTAL WAGES PAID. 1) $ . 2) $ . 3) $ . 4) $ . 5) $ . 6) $ . 7) $ . 8) $ . 9) $ . 10 ) $ . 11 ) $ . 12 ) $ . 13 ) $ . 14 ) $ . 15 ) $ . 16 ) $ . 17 ) $ . 18 ) $ . 19 ) $ . 20 ) $ . 21 ) $ . 22 ) $ . 23 ) $ . 24 ) $ . 25 ) $ . 26 ) $ . TOTAL WAGES FOR THIS PAGE $ . DWS-ARK-209C. (REV. 06-06).